Development of Scoring Criteria for the Clock

Drawing Task in Alzheimer's Disease

Mario F. Mendez, MD, PhD,*t$ Thomas Ala, MD,*t and Kara L. Underwood, BS*$
~~~~ ~~ ~ ~~

Objective: To investigate the reliability and validity of free-
hand clock drawings, a frequently used measure of construc-
tional apraxia, in patients with Alzheimer's disease.
Design: Survey for the purpose of testing reliability and
validity of a new scale.
Setting: Memory Disorder Clinic at a university-affiliated
hospital in the Upper Midwest.
Patients: Forty-six patients were diagnosed with clinically
probable dementia of the Alzheimer type after a dementia
evaluation, and 26 normal elderly controls were research
volunteers without a history of cognitive dysfunction.
Measurements: Neuropsychological tests, dementia-related
scales, and clock drawings rated by a new 20-item Clock
Drawing Interpretation Scale. Reliability measures, correla-
tions, and clustering of items in the CDIS.
Results: The CDIS had inter-rater reliability (r = .94),internal
consistence (r,, = .95), and reproducibility over a 6-month
interval. CDIS scores were significantly correlated with two
dementia-relatedscales and all neuropsychological tests and
had the highest correlationswith other measures of construc-
tional apraxia. All but four Alzheimer patients (91%) and
none of the controls had CDIS scores of 18 or less.
Conclusion: Clinicians may reliably screen patients with
Alzheimer's disease with the clock-drawing task, a measure
sensitive to deficits in constructional apraxia. J Am Geriatr
SOC401095-1099,1992

any clinicians use the clock drawing task to (HAM-D) scores of less than 16.9 Patients were ex-

M screen dementia patients for visuoconstruc-

tional difficulties.1 Constructional apraxia is
a common neuropsychological disturbance in dementia
cluded if they had neurobehavioral or psychiatric ill-
nesses other than dementia, significant medical ill-
nesses or visual impairments, psychoactive drug use,
or medication effects. The 46 AD patients were com-
and often occurs early in the course of the disease.'
The freehand drawing of a clock may be a sensitive pared with 26 normal elderly controls without history
measure of constructional apraxia; however, the meth- of cognitive impairment.
ods of interpretation of the clock-drawing task in de- Procedures The CDIS was developed from data on
mentia have varied from a simple qualitative assess- types of errors committed by AD patients. Pilot data
ment of abnormality to diverse scales.',3 It is not fully led to the selection of 31 items that were easily scorable
established whether the clock-drawing task can be by unsophisticated observers. We retained the 20 items
scored in a simple, reliable, and valid manner. In with high correlations (r = -41-.81; all P < 0.001) with
addition, the production of drawings involves several the CDIS total score. (See Appendix)
cognitive f~nctions,~ and the interpretation of an ab- The administration of the clock-drawing task in-
normal clock drawing could disclose cognitive deficits volved the presentation of a blank, white, S1h" X 11"
other than constructional a ~ r a x i a . ~ paper with the instructions to draw a clock. This com-
We evaluated the clock-drawing task in well char- mand was given both orally and in writing and was
acterized patients with Alzheimer's disease (AD) and repeated as necessary. After the initial clock-drawing
normal elderly controls. We developed an easily scor- attempt, subjects were asked both orally and in writing
able Clock Drawing Interpretation Scale (CDIS) and to indicate the time as ten after eleven. Two naive
assessed the reliability, validity, and discrimination raters were instructed in the use of the CDIS and then
ability of the CDIS in relation to neuropsychological independently and blindly rated each clock drawing
tests and dementia-related scales. with the CDIS.
For comparison, we administered neuropsychologi-
MATERIALS AND METHODS cal tests including: (1) the Letter Cancellation Test,"
Subjects We identified 46 patients who met estab- (2) the Grooved Pegboard Test," (3) the Symbol Digit
lished criteria for clinically probable dementia of the Modalities Test,'' (4) the Benton Facial Recognition
Alzheimer type.6 Inclusion criteria required at least an Test, short form,I3 (5) a simplified version of the Rey
eighth grade level of education, no abnormalities on Complex Figure Test,I4 (6) the Buschke Selective Re-
computed tomograms of the head other than cerebral minding Test,I5(7) the Controlled Word Fluency Test,16
atrophy, Mini-Mental State Examination (MMSE) and (8) four scales: the Mini-Mental State Examina-
scores of 13-23,7 Blessed Dementia Scale (BDS) scores t i ~ nthe , ~ Blessed Dementia Scale,' the Global Deteri-
of 6-19,' and Hamilton Rating Scale for Depression oration Scale for AD,17 and the Intsrumental Activities
of Daily Living Scale."
All 72 subjects were evaluated at baseline, and, for
From the 'Department of Neurology, tMemory Disorders Clinic, and $The further reliability assessment, 42 AD patients com-
Neurocognitive Laboratory, St. Paul-Ramsey Medical Centermniversity of pleted clock drawings and dementia-related scales on
Minnesota, St. Paul, Minnesota.
Address correspondence to M.F. Mendez, MD, PhD, Dept. of Neurology, St. two more sessions at 12 weeks and at 24 weeks from
Paul-Ramsey Medical Center, 640 JacksonSt., St. Paul, MN 55101. baseline.

IAGS 40:1095-1099, 1992

0 1992 by the American Geriatrics Society 0002-8614/92/$3.50
1096 MENDEZ ET AL
Data Analysis The CDIS was evaluated for inter-
rater reliability, internal consistency (Kuder-Richardson
Formula 20 - rtt), and change over the three testing
sessions (repeated measures analysis of variance). We
assessed item analysis and correlations between CDIS
scores and neuropsychological measures.
RESULTS
Subjects There were no significant age or sex dif-
ferences between the baseline AD patients (mean age
70.7 It 8.0; range 51-84; 18 men, 28 women) and the
controls (69.3 f 7.9; range 59-83; 10 men, 16 women).
The AD patients were in a mild-moderate stage of
dementia with a mean duration of illness of 4.1 f 2.1
years. The mean education in years was 12.0 f 2.7 for
the AD patients and 12.1 5 2.9 for the controls. The
elderly controls were screened with the MMSE, and all
obtained a score of 28 or above as well as scores in the
normal range on the subsequent neuropsychological
tests administered here.
For the 72 subjects at baseline, there were significant
differences on the CDIS between AD patients and
controls (AD patients 11.8 f 4.2, controls 18.2 f 0.8; t
test = 7.67; P < .001). All CDIS items were missed by
one or more AD patients (See Figure 1). Using a cut-
off CDIS score of greater than 18, all the normals were
identified, and only four AD patients were included.
CDIS Reliability The inter-rater reliability for the
two raters was r = .94 for both the 72 baseline clock
drawings and for the entire 156 clock drawings (in-
cludes the 42 drawings at both 12 weeks and 24 weeks).
The internal consistency of the baseline CDIS scores
was rtt = .95.
The test-retest correlations for the 42 AD patients
who were serially tested were high (r = .78 for baseline-
week 12; r = .76 for baseline-week 24; r = .70 for week
12-week 24; all P < 0.001) and there were no signifi-
cant changes in CDIS scores over the 6 months (See
Table 1).Had disease not progressed in many subjects
as reflected by declines in the MMSE and the IADL,
the CDIS test-retest reliability might have been higher.
CDIS Validity The correlations between the CDIS
scores and the neuropsychological tests ranged from r
= -21-.66, and all reached statistical significance (See
Table 2). The highest correlations were with the two
tests most affected by constructional apraxia: the Rey
Complex Figure copy (r = .66) and the Symbol Digit
Modalities Test (r = .65). In the 46 baseline AD pa-
tients, the CDIS also correlated with the Mini-Mental
State Examination (T = .45, P < .001) and the Global
Deterioration Scale (r = .40;P < .001) but not with the
other dementia-related scales.
Item Analysis Except for Item No. 15, all items
adequately discriminated AD patients from controls
(Index of Discriminability of 20 or more; See Table 3).19
Item No. 4 (A '2" is present on the clock and is pointed
out in some way when indicating the time) was the
most frequently missed item and the only one missed
by all AD patients.
Inter-item correlations were examined for clusters of
abnormalities. The CDIS items could be divided into
IAGS-NOVEMBER 1992-VOL. 40, NO. 11
FIGURE 1. Representative clock drawings by Alzheimer's disease
patients.
A. CDIS score: 15 (missed item nos. 4, 5, 12, 15, 17). This clock
scores correctly on item no. 8 because of a '9" bordering the third
quadrant.
8.CDIS score: 13 (missed item nos. 4, 5, 7, 11, 13, 14, 17). This clock
scores incorrectly on item no. 11 because the only sequential numbers
run from 3 to 8. The first two symbols are "one" and "t" and the last
five are 'E" through "I."
C. CDIS score: 12 (missed item nos. 4,5, 9, 13-15, 17, 18). This clock
exemplifies item nos. 9, 13, and 16. Numbers are substituted with
"H", one of which is not adjacent to the closure figure edge, and the
hand, although not touching the center, radiates from it.
D. CDIS score:.7 (missed item nos. 2, 4, 5, 7-10, 15-20). There is no
attempt to indicate a time on this clock (item no. 2). There are no
hands so item nos. 16-20 do not need to be individually scored.
E. CDIS score: 8 (missed item nos. 2-5, 7, 8, 14, 16-20). This clock
illustrates item no. 3, the addition of extra types of items, ie, the
words 'TIME" and "PM."
F. CDIS score: 15 (missed item nos. 4, 9, 14-16). This patient missed
item 15 because there is a very small '10" barely visible at the
junction of the two hands.
G. CDIS score: 14 (missed item nos. 1, 4, 5, 7, 8, 10). In this clock,
the numbers are counterclockwise (item no. 10) and the closure
figure has a small gap (item no. l), but there is a slightly larger
"minute hand" (item no. 17).
H. CDIS score: 11 (missed item nos. 1, 4-6, 9, 15, 17-19). This clock
has numbers and hands outside of the closure figure (item nos. 6
and 19), but most still form a circle without gaps (item no. 7). Note
that the topmost number is a barely recognizable '12."
three groups based on intercorrelations of r z .5. Group
1 (Item Nos. 1, 3, 4, 6, 9, 14, and 16-20) had r = .56-
.76 correlations with each other and r c: .36 with the
remaining items. Group 2 (Item Nos. 2, 5, 8, and 11)
had r = .58-.74 correlations with each other and r 5
.22 with the items in Group 3. Group 3 (Item Nos. 7,
10, 12, 13, and 15) had r = .62-.85 intercorrelations.
Item-test correlations corresponded with these three
groups with a few exceptions: Item No. 12 significantly
correlated with all the tests and Item Nos. 2 and 14
with the Rey Complex Figure copy only. The remaining
items in Groups 1 and 2 had correlations of Y = .52-
.74 (using only positive values) with all tests except the
Buschke Selective Reminding Test (r 5 .25) and the
Controlled Word Fluency Test ( Y = .22). Furthermore,
the items in Group 1 had their strongest correlations
with the Rey Complex Figure copy, and the items in
Group 2 had their strongest correlations with the Letter
Cancellation Test. Group 3 items did not have Y 2 .5
correlations with any of the neuropsychological tests.
IAGS-NOVEMBER 1992-VOL.40, NO. 11 CLOCK DRAWING IN ALZHEIMER’S DISEASE 1097
TABLE 1. ALZHEIMER PATIENTS: CDIS SCORES AND DEMENTIA-RELATED SCALES OVER SIX MONTHS
Baseline 12 weeks 24 weeks
F* Significance
Mean SD Mean SD Mean SD (41.84) Level (PI
~

CDIS 11.9 4.2 10.7 5.4 10.8 5.8 2.42 .095

MMSE 17.5 3.2 18.0 4.2 16.8 4.7 3.64 .031**
IADL 17.4 4.1 18.3 3.8 19.3 4.3 7.09 .001**
Blessed 8.8 2.0 8.6 3.3 9.5 3.6 1.95 .149
GDS 4.4 0.7 4.5 0.5 4.6 0.6 1.57 .214
* Repeated measures analysis of variance.
** Significant deterioration in dementia scale over the 6 month interval.
CDIS = Clock Drawing Interpretation Scale; MMSE = Mini-Mental State Examination; IADL = Instrumental Activities of Daily Living Scale; Blessed
= Blessed Dementia Scale; GDS = Global Deterioration Scale.

TABLE 2. ATTRIBUTES OF ALZHEIMER PATIENTS AND NORMAL CONTROLS

46 AD pts. 26 Normals*
Correlation
Mean SD Mean SD with CDIS**
Letter Cancellation
Errors 20.7 18.9 3.7 3.7 -.53
Time 321.7 159.7 169.2 50.1 -.44
Grooved Pegboard
Left 138.8 54.3 91.9 21.5 -.44
Right 126.8 41.7 82.8 20.5 -.49
Symbol Digit Modalities 10.6 10.5 41.0 12.7 .65
Benton Facial Recognition 37.9 6.0 45.2 4.6 .47
Rey Complex Figure - Copy 12.0 7.1 18.3 2.2 .66
30 min Delayed Recall 1.4 3.5 16.0 3.2 .49
Buschke Selective Reminding Test
Longterm Storage 2.4 2.0 7.9 1.6 .21
Longterm Retrieval 20.2 15.7 61.5 12.4 .27
Recognition 4.6 2.7 8.7 0.9 .31
Controlled Word Fluency 25.1 9.9 38.7 11.4 .33
* The CDIS and all the neuropsychological test results were significantly different (t test, P < 0.001) between the A D patients
and the normal elderly
controls.
** The CDIS correlations were all significant to the P < 0.001 level except for Buschke longterm storage which was significant to P < 0.01.

TABLE 3. CDIS ITEM ANALYSIS AND DISCRIMINABILITY

Number Correct (9%)
46 AD pts. 26 Normals Total
Index of
CDIS Item No. (%) No. (%I No. (%) Discriminability
General items
1. 28 (61) 26 (100) 54 (75) 39
2. 30 (65) 23 (88) 53 (74) 23
3. 34 (74) 24 (92) 58 (81) 18
“Number”items
4. 0 (0) 19 (73) 19 (26) 73
5. 13 (28) 25 (96) 38 (53) 68
6. 18 (39) 26 (100) 44 (61) 61
7. 35 (49) 26 (100) 61 (85) 51
8. 18 (39) 22 (85) 40 (56) 46
9. 18 (39) 23 (88) 41 (57) 49
10. 26 (57) 26 (100) 52 (72) 43
11. 25 (54) 25 (96) 50 (69) 42
12. 32 (70) 26 (100) 58 (81) 30
13. 36 (78) 26 (100) 62 (86) 22
14. 37 (80) 26 (100) 63 (88) 20
15. 40 (87) 26 (100) 66 (92) 13
‘Hands” items
16. 10 (22) 22 (85) 32 (44) 63
17. 20 (43) 26 (100) 46 (64) 57
18. 24 (52) 26 (100) 50 (69) 48
19. 26 (57) 26 (100) 62 (86) 43
20. 27 (59) 26 (100) 63 (88) 41
1098 MENDEZ ET AL
DISCUSSION
The clock drawings of dementia patients were reli-
ably assessed, were consistent with other measures of
constructional apraxia, and distinguished normal el-
derly subjects from impaired patients with Alzheimer's
disease. All of the normal subjects missed two or fewer
items compared with 8.7% of the AD patients. More-
over, there were statistically significant correlations of
the CDIS with all of the neuropsychological tests and
with the cognitively oriented scales (MMSE and GDS),
but not with functionally oriented scales (Blessed and
IADL).3r20
The drawing of a clock without a model requires
reconstructing, to a verbal command, the memory of a
clock into a graphic image.21,22This "constructional
praxis" involves visuoperceptual analysis but is also
affected by motor execution, attention, language com-
prehension, and numerical knowledge. Focal right-
hemisphere lesions may result in abnormal clock draw-
ings solely from impaired visuoperceptual analy-
sis.2.21,23 Left-hemisphere lesions may disturb this task
by an executive motor deficient language
c ~ m p r e h e n s i o nor
, ~a~disturbed
~~~ mental image of the
clock." Visual attentional disturbances or frontal ex-
ecutive disorders can also disrupt the clock-drawing
task." The drawings of AD and other dementia pa-
tients may include all of these elements. Their drawings
can display a loss of spatial relationships as seen with
right-hemisphere lesions, a simplification as seen with
left-hemisphere lesions, executive disturbances from
frontal lesions, and a probable synergistic interaction
of all these disturbance^.'*^
In our AD patients, the main disturbance on the
clock drawings resulted from abnormal visuopercep-
tual analysis, as reflected in the high correlations of
most items (Group 1) with neuropsychological tests
with visuoperceptual elements. However, other cogni-
tive disturbances probably contributed to the abnor-
malities on the clock-drawing task. Several items
(Group 2) had their largest correlations with measures
sensitive to attention disturbances (eg, the Letter Can-
cellation Test). Moreover, there were number-related
items (Group 3) that were not correlated with any test
and that may have reflected "numerical" factors not
assessed by our neuropsychological tests.
In sum, the clock-drawing task interpreted with an
instrument such as the CDIS can be a valuable addition
to dementia screening evaluations. This task is simple,
takes less than a minute to score with the CDIS, and
reflects constructional apraxia due to visuoperceptual
and other cognitive disturbances. Normal elderly sub-
jects miss less than two items on the CDIS, and AD
patients tend to miss three or more. The CDIS has
additional potential value for the retrospective scoring
of previously obtained clock drawings. Future studies
should cross-validate the CDIS in a longitudinal study
of larger numbers of patients with AD as well as with
other dementias.
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APPENDIX
CLOCK DRAWING INTERPRETATION SCALE
(Score "1" per Item)
-1. There is an attempt to indicate a time in any
way.
--2. All marks or items can be classified as either part
of a closure figure, a hand, or a symbol for clock
numbers.
--3. There is a totally closed figure without gaps
(closure figure).
Score Only if Symbols for Clock Numbers Are Present:
--4. A '2" is present and is pointed out in some way
for the time.
--5. Most symbols are distributed as a circle without
major gaps.
-6. Three or more clock quadrants have one or more
MGS-NOVEMBER 1992-VOL.40, NO. 11 CLOCK DRAWING IN ALZHEIMER'S DISEASE 1099

appropriate numbers: 12-3, 3-6, 6-9, 9-12 per ---15. Seven or more of the same symbol type are
respective clockwise quadrant. ordered sequentially.
--7. Most symbols are ordered in a clockwise or
rightward direction. Score Only if One or More Hands Are Present:
--8. All symbols are totally within a closure figure. ---16. All hands radiate from the direction of a closure
--9. An "11" is present and is pointed out in some figure center.
way for the time. ---17. One hand is visibly longer than another hand.
---lo. All numbers 1-12 are indicated. ---18. There are exactly two distinct and separable
--11. There are no repeated or duplicated number hands.
symbols. ---19. All hands are totally within a closure figure.
--12. There are no substitutions for Arabic or Roman --20. There is an attempt to indicate a time with one
numerals. or more hands.
----13. The numbers do not go beyond the number 12.
---14. All symbols lie about equally adjacent to a
closure figure edge. Total Score (Maximum score of 20)